Comparison of Endoscopic Papillary Large Balloon Dilation and Endoscopic Sphincterotomy for Retrieval of Choledocholithiasis

Background: Endoscopic sphincterotomy (EST) combined with balloon catheters and/or baskets are the routine endoscopic techniques for stone extraction in the great majority of patients. Whereas large common bile duct (CBD) stones are treated conventionally with mechanical lithotripsy, large balloon papillary dilation after endoscopic sphincterotomy (ELPBD) represents the onset of an era in large CBD stone extraction and the management of “impaction”. That is because it seems effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. Studies comparing the efficacy and safety of EPLBD with EST have reported mixed outcomes. The aim of the study to compare the success and complications rates between endoscopic papillary balloon dilation and endoscopic sphincterotomy for enlargement of papillary opening during endoscopic removal of common bile duct stones. Methods: Randomized prospective comparative study was conducted on seventy four patients with CBD stone(s), subjective to therapeutic ERCP procedures for endoscopic extraction of common CBD(s). The enrolled patients were randomly divided into two groups according to the maneuver for dilate the papillary orifice into: Group I: Thirty one patients underwent EPLBD technique combined with balloon catheters and/or baskets for stone extraction. Group II: Forty three patients underwent EST combined with balloon catheters and/or baskets, which is considered as conventional endoscopic technique for stone extraction in the great majority of patients. Results: Complete extraction CBD stones among the patients of group1; EPLBD was effective for clearance of (92.5%) of CBD stones in patients with the stone sized 1cm, (overall clearance rate=87%). Overall adverse effects of patients of group1 was (29%) as mild self-limiting post ERCP pain occurred in (9.6%) and mild intra- procedure bleeding occurred in (9.6%), whereas more serious complication as melena which occurred in (3.2%), and mild pancreatitis occurred in (6.4%). Whereas complete CBD stones clearance among the patients of group 2; EST was effective in (96%) of patients with the stone sized 1cm, (overall clearance rate=79%). Overall adverse effects of patients of group 2 was (18.5%) as mild self-limiting post ERCP pain occurred in (7%) and mild intra-procedure bleeding occurred in (4.6%), whereas more serious complications as mild pancreatitis developed in (4.6%), and post ERCP cholangitis in (2.3%). The comparison between the two groups regarding the extraction of CBD stones revealed combination of papillary large balloon dilation after EST is not required in patients whose the CBD stone size 1cm among the group 1 was (83%) which better than among the group 2 which was (56%) with nearly statistical difference (P value=0.07). Conclusion: Conventional EST is an effective method for removal of common bile duct stones 1cm which is difficult to be extracted by conventional sphincterotomy and extraction devices. Endoscopic papillary large balloon dilation is an adjunctive tool to endoscopic sphincterotomy for removing large or difficult CBD stones.